Health inspection·December 11, 2025

§483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. 22 CCR § 72315 - Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 22 CCR § 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. 72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 10/14/2025, the California Department of Public Health (CDPH) received a facility reported incident (FRI) alleging Resident 2 threw a hard plastic coffee mug at Resident 1's head. On 10/28/2025, CDPH conducted an unannounced visit to the facility to investigate the FRI allegation. The facility failed to: 1.Ensure Resident 1 was not abused by Resident 2 on 10/11/2025 at approximately 7:00 p.m., while they were smoking on the patio. 2. Ensure Resident 1 and Resident 2 were supervised on 10/11/2025 at approximately 7:00 p.m., while they were smoking on the patio. 3. Secure the door leading to the smoking patio after the last scheduled smoking time at 6 p.m. in accordance with facility's P&P titled, "Smoking Policy-Residents," undated, which indicated the facility will establish and maintain safe resident smoking practices. 4. Ensure Certified Nursing Assistants (CNA) 2 redirected Resident 2 to the resident's room instead of leaving Resident 2 unattended in the smoking patio on 10/11/2025. 5. Ensure CNA 1 was aware of Resident 1's whereabouts on 10/11/2025 at 7:00 p.m. 6. Follow the facility's policy and procedure (P&P) titled "Abuse and Neglect - Clinical Protocol," which indicated the facility will implement measures to address resident needs and minimize the risk of abuse and neglect. As a result, Resident 2 threw a hard plastic coffee mug at the right side of Resident 1's head. Resident 1 sustained a bump on the right side of the head and complained of headache rated 3 out of 10 on a zero to ten numeric pain scale (0= no pain, 1 to 3 =mild pain, 4 to 6=moderate pain and 7 to 10 = severe pain). A review of Resident 1's Admission Record indicated Resident 1, a 71-year-old female, was admitted to the facility on 2/17/2025 and readmitted on 8/30/2025 with diagnoses included anxiety disorder, repeated falls, recurrent major depressive disorder, and unspecified fracture of shaft of left tibia. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 9/5/2025, indicated Resident 1 had intact cognition and required substantial assistance with bathing, chair/bed to chair transfer, and sit to stand. A review of Resident 1's Smoking Safety Screen dated 10/6/2025 indicated Interdisciplinary Team (IDT) determined Resident 1 was safe to smoke with supervision and required a smoking apron. A review of Resident 1's Change in Condition (COC) dated 10/11/2025 and timed at 9:07 p.m., indicated Resident 1 approached Licensed Vocational Nurse (LVN) 1 and asked for pain medication because her head hurt. The COC indicated Resident 1 stated Resident 2 threw a hard plastic cup and hit her (Resident 1's) head on the patio. The COC indicated LVN 1 assessed Resident 1's head and observed a bump on the right side of the head. The COC indicated Resident 1 complained of a headache rated at 3 out of 10. The COC indicated Resident 1 was given Tylenol for pain and an ice pack was applied to the bump on the right side of the head. A review of Resident 1's Progress Note dated 10/13/2025 timed at 1:38 p.m., indicated Resident 1 complained of head discomfort with pain rated at 5/10 and the resident requested to be sent to the general acute care hospital (GACH). The Progress Note indicated Resident 1 received Oxycodone (medication used to treat moderate to severe pain) 10 milligrams (mg) for pain and an ice pack applied to the resident's head. The Progress Note indicated Resident 1's physician was notified and Resident 1's physician ordered for the staff to monitor and observe Resident 1. A review of Resident 1's Medication Administration Record dated 10/13/2025, indicated on 10/13/2025 at 3:30 p.m. Resident 1 complained of head pain rated 8/10 and was given Oxycodone 10 mg. A review of Resident 2's Admission Record, indicated Resident 2, a 73-year-old female, was admitted to the facility on 10/6/2025 with diagnoses included dementia (loss of memory, language, problem-solving and other thinking abilities), depression, and hypertension. A review of Resident 2's MDS dated 10/10/2025, indicated Resident 2 had severely impaired cognitive skills and required supervision or touching assistance with chair/bed to chair transfer, sit to stand and walking within 10 feet. A review of Resident 2's Smoking Safety Screen dated 10/7/2025, indicated the resident had cognition loss and required a smoking apron. The Smoking Safety Screen indicated the IDT determined Resident 2 was safe to smoke with supervision. A review of Resident 2's COC dated 10/11/2025 timed at 10:50 p.m. indicated Resident 2 had an episode of physical aggression and allegedly hit another resident with a hard plastic cup. During an interview on 10/28/2025 at 12:10 p.m. Resident 1 stated there were no facility staff or other residents present on the patio on 10/11/2025 at the time when Resident 2 threw a hard plastic cup at her. Resident 1 stated she was listening to music from Resident 3's cellphone, which was on the table, along with a sandwich. Resident 1 stated Resident 2 grabbed the sandwich and Resident 3's cellphone and became verbally aggressive when Resident 1 asked Resident 2 to put the sandwich and cellphone down. Resident 1 stated Resident 2 threw the sandwich to the ground and threw a hard plastic coffee mug, striking her on the right side of her head (Resident 1). Resident 1 stated she sustained a bump on the head and had a headache following the incident. Resident 1 stated residents sometimes stayed on the patio playing cards unsupervised even after the designated smoking times. During an interview on 10/28/2025 at 1:06 p.m. Resident 2 stated she did not remember what happened and denied hitting Resident 1's head with a hard plastic coffee mug. During a telephone interview on 10/28/2025 at 2:18 p.m., CNA 1 stated she was unaware of the incident occurring on the smoking patio involving Resident 1 and Resident 2 on the evening of 10/11/2025. CNA 1 stated she was assigned to Resident 1, and she did not know Resident 1 was outside on the patio at 7 p.m. CNA 1 stated CNAs were responsible for knowing the whereabouts of residents, and residents were expected to be monitored every two hours. CNA 1 stated the lack of supervision and monitoring could lead to accidents or physical altercations (arguments or disagreement) among residents. During an interview on 10/28/2025, at 2:59 p.m. Licensed Vocational Nurse (LVN) 1, stated on 10/11/2025 at approximately 8:00 p.m., Resident 1 requested pain medication for a headache, which led to the facility becoming aware of the altercation between Resident 1 and Resident 2. LVN 1 stated she assessed Resident 1 and observed a small bump on the right side of her head. LVN 1 stated she was unaware Resident 1 was unsupervised on the smoking patio. LVN 1 stated residents were supposed to be monitored hourly, and CNAs were responsible for checking residents' whereabouts when LVNs were administering residents' medications. LVN 1 stated knowing residents' whereabouts was essential to ensure their safety and well-being. LVN 1 also stated the smoking patio door remained open and unlocked after the last scheduled smoking time of 6:00 p.m., daily. During a telephone interview on 10/28/2025 at 5:09 p.m., CNA 2 stated on 10/11/2025 she should not have left Resident 2 unsupervised on the patio after the designated smoking time of 6 p.m., due to safety concerns. CNA 2 stated she was unaware of the altercation that occurred between Resident 1 and Resident 2. She stated the last time she saw Resident 2 on 10/11/2025 was at approximately 7:00 p.m., on the smoking patio with Resident 1. CNA 2 stated she assumed the residents were outside to get fresh air, though it was after the scheduled smoking time. CNA 2 stated at the time of the incident, she was providing care to her assigned residents. CNA 2 stated she did not redirect Resident 2 to her room. CNA 2 stated if she had redirected Resident 2 back to her room, the altercation may have been prevented. CNA 2 stated leaving residents unsupervised on the smoking patio placed residents at risks for incidents, including falls and resident-to-resident altercations. During a telephone interview on 10/29/2025 at 4:45 p.m., LVN 2 stated Resident 2 had a short temper, occasionally displayed mild anxiety, and often required redirection from staff. LVN 2 stated some residents, including Resident 1 and Resident 2, remained on the smoking patio after smoking scheduled times because they enjoyed listening to music. LVN 2 stated on 10/11/2025, Resident 1 expressed a desire to stay on the patio to listen to music. LVN 2 stated she did not know why CNA 2 left the residents unsupervised on the patio. LVN 2 stated CNAs were responsible for returning residents to their rooms after smoking sessions. LVN 2 stated residents should not remain on the patio unsupervised due to safety concerns, including the potential for falls or altercations. During an interview on 10/29/2025 at 3:54 p.m., Registered Nurse Supervisor (RNS 1), stated if residents used the smoking patio for socialization, there should be staff present to supervise them. RNS 1 stated staff supervision was necessary to prevent incidents that could escalate into altercations among residents and to ensure resident safety. During an interview on 10/29/2025 at 2:17 p.m., the Activity Director (AD), stated the facility's last scheduled smoking time was between 6:00 p.m. and 6:30 p.m. The AD stated after this time, the door to the smoking patio was supposed to be locked to prevent residents from accessing the area without staff supervision. During an interview on 10/30/2025 at 3:55 p.m., the Director of Nursing (DON), stated residents should be supervised while on the smoking patio, including after smoking times, for safety reasons. The DON stated after the final smoking period (between 6:00 p.m. and 6:30 p.m.), staff were expected to escort residents back to their rooms and lock the patio door. The DON stated the incident between Resident 2 and Resident 1 could have been prevented if the residents were supervised while on the smoking patio after smoking time or redirected to their rooms. The DON stated leaving residents unsupervised on the patio could lead to unusual or unsafe situations, including falls or resident-to-resident arguments, which may escalate into verbal or physical abuse. A review of facility's policy and procedure (P&P) titled," Abuse and Neglect- Clinical Protocol," revised 3/2018, the P&P indicated the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. A review of facility's P&P titled, "Smoking Policy-Residents," undated, indicated the facility will establish and maintain safe resident smoking practices. The P&P indicated any smoking-related privileges, restrictions on a resident like the need for close monitoring are noted in their care plan and all personnel caring for the resident will be alerted to these issues. A review of facility's Smoking Schedule indicated smoking times of 9 a.m. to 9:30 a.m.;11 a.m. to 11:30 a.m.; 1:30 p.m. to 2:00 p.m.; and 6 p.m., to 6:30 p.m. The facility failed to: 1.Ensure Resident 1 was not abused by Resident 2 on 10/11/2025 at approximately 7:00 p.m., while they were smoking on the patio. 2.Ensure Resident 1 and Resident 2 were supervised on 10/11/2025 at approximately 7:00 p.m., while they were smoking on the patio. 3. Secure the door leading to the smoking patio after the last scheduled smoking time at 6 p.m. in accordance with facility's P&P titled, "Smoking Policy-Residents," undated, which indicated the facility will establish and maintain safe resident smoking practices. 4. Ensure Certified Nursing Assistants (CNA) 2 redirected Resident 2 to the resident's room instead of leaving Resident 2 unattended in the smoking patio on 10/11/2025. 5. Ensure CNA 1 was aware of Resident 1's whereabouts on 10/11/2025 at 7:00 p.m. 6. Follow the facility's policy and procedure (P&P) titled "Abuse and Neglect - Clinical Protocol," which indicated the facility will implement measures to address resident needs and minimize the risk of abuse and neglect. As a result, Resident 2 threw a hard plastic coffee mug at the right side of Resident 1's head. Resident 1 sustained a bump on the right side of the head and complained of headache rated 3 out of 10 on a zero to ten numeric pain scale (0= no pain, 1 to 3 =mild pain, 4 to 6=moderate pain and 7 to 10 = severe pain). These violations had a direct or immediate relationship to the health, safety, or security of Resident 1.